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Excellence in the care of older people: case report 4

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VOL: 96, ISSUE: 37, PAGE NO: 46

Sue Davies, MSc, BSc, RGN, RHV, lecturer at nursing at University of Sheffield

Jayne Brown, MMedSci, RGN, lecturer at nursing at University of Sheffield;Fiona Wilson, MSc, BSc, RGN, is research fellow at the Sheffield Institute for Studies on Ageing;Mike Nolan, PhD, MSc, MA, RGN, RMN, is professor of gerontological nursing at the University of Sheffield

In 1999, the charity Help the Aged commissioned research on good practice in acute hospital care for older people. As part of this work we focused on two wards at Kidderminister General Hospital, which serves a rural area. One of the hospital's most striking features is its strong links with the surrounding community. We found this was reflected in the sense of ownership expressed by both staff and patients and by the input of the local community through consultation and fund-raising.

In 1999, the charity Help the Aged commissioned research on good practice in acute hospital care for older people. As part of this work we focused on two wards at Kidderminister General Hospital, which serves a rural area. One of the hospital's most striking features is its strong links with the surrounding community. We found this was reflected in the sense of ownership expressed by both staff and patients and by the input of the local community through consultation and fund-raising.

The hospital's medical unit, within which the two wards are managed, provides integrated acute care for adult patients of all ages. A medical admissions ward acts as an acute assessment unit; once stable, patients are transferred to other wards within the directorate.

Ward A1 is a 28-bed women's acute medical ward where treatment that is begun on the admissions ward can be continued. Ward A2 is a 32-bed men's equivalent of Ward A1 with additional beds for haematological, HIV and AIDS patients. Some day care is also provided.

Patient experiences
The patients and relatives we spoke to at this site particularly appreciated the fact that staff kept them well informed.

One said: 'They tell me what the medications are for. They say to me: 'Take that one half an hour before your meal because it's a pain killer.' They explain to me what the doctor has prescribed. And they leave the [patient] notes about - you can sit and read your notes if you want to. I didn't but my daughter did.'

Interactions between staff and patients show a positive attitude towards older people. One ex-patient commented. 'They really are great, I have nothing but admiration. There's a nice atmosphere. It's a delight.'

The ward environment
Although both wards provide highly technical care for acutely ill patients, staff have managed to create a comfortable, relaxed environment. Spacious, six-bed bays are situated off a wide corridor with side wards to one side. Spacious surroundings allow patients to maximise their personal space within a clinical environment. The ward layout allows privacy but also company for patients. Bays are clearly laid out and labelled, which helps patients and their families find their way around the ward.

The physical map of the ward complements the organisation of nursing care, which is split into two teams. There are two separate nursing stations located in the ward area, encouraging staff to be 'out there' and visible. The large ward area enables patients to take part in occupational therapy and physiotherapy on the ward, rather than having to go to a separate area.

The day-room has been upgraded through the efforts of local fund-raisers to a design planned by one of the health care support workers. The room is decorated in a non-institutional, light and airy style, with sofas, a pine fireplace and pine table, producing a homely effect.

In addition, Ward A2 has a large, modern conservatory. Like the day room, this seems to be used by staff, patients and relatives to take time out from the routine of the wards to relax.

An attractive coffee bar and dining room are available for staff and patients, with food served throughout the day. Visitors are encouraged to use these facilities and there is a large menu board in the foyer to tempt the appetites of those arriving. Visitors commented that this is particularly useful for people who have come a long distance and those visiting over long periods.

Partnerships in care
Carer involvement is regarded as integral to planning effective care throughout a patient's stay. This results in a reciprocal relationship in which carers can give a broader picture of a patient's health and social needs, while staff can identify carer and patient needs. There is evidence that this approach results in negotiated care that is truly in line with the wishes of patients and family carers.

However, staff are also aware of the need to negotiate the degree of involvement with families and carers. The ward sister described working with the wife of a patient who had had a severe stroke. Both the wife and her husband were determined that he should be cared for at home. Despite concerns that the caring demands would be too great for the wife, the team worked hard to negotiate a supportive care package, and he was discharged home.

A sense of community involvement is reflected in the fund-raising activities of local people. For example, a side room on Ward A1 has been developed through the money-raising efforts of two retired hospital workers. This is a large, attractive room overlooking gardens, with emergency call bell, television, and clinical equipment.

One part of the room can be separated by a divider and has a modern sofa bed, TV and ensuite facilities. This suite allows for patients and relatives to be together, and is much appreciated, particularly by patients admitted for palliative care. One relative said: 'They took her to the side ward so everyone could be with her.'

A number of initiatives are aimed at strengthening communication between disciplines and management levels. For example, a regular multidisciplinary training day has been introduced with the purpose of team-building and problem-solving.

A 'clinical effectiveness group' is another initiative aimed at ensuring the most appropriate care for patients on the unit. This group began as a fairly informal get-together, but the multidisciplinary approach to assessing practice has attracted staff from all disciplines. This has resulted in a sense of ownership of practice developments and recognition that all grades of staff can contribute.

Developing staff
Despite uncertainties about closure of the hospital, senior staff have made professional development for staff a priority. One ward sister, for example, described her own career pathway: 'For 20 years I was on nights as an E-grade SEN. I did my conversion in 1996, a diploma and then a degree.'

This ward manager was similarly willing to develop her own staff and was keen to identify learning needs and development opportunities. All staff nurses are supported to develop management skills, and all health care assistants take NVQs. Continuing to invest in staff has also helped to maintain morale.

Developing practice
In spite of job insecurities, staff also appear to respond positively to practice development initiatives. A recent example involved the development of a risk-assessment tool for patients vulnerable to falls, which has raised awareness of safety issues. Such collaboration has led to greater understanding between professions and has increased the sense of ownership of changes in practice.

Link nurses working with dietitians have developed an assessment tool that provides a resource for ensuring appropriate nutritional care. This collaboration has resulted in better multidisciplinary understanding while also benefiting patient care. Nurses can now assess nutritional needs more accurately and refer appropriately, while the dietitians have a better understanding of the nurses' contribution to nutritional care.

Leadership at senior management level is focused on creating a culture of openness and reflective practice. Strategies include addressing complaints openly and quickly, and using discussions with ward staff and managers to reflect on patient outcomes. Audit of critical incidents encourages staff to identify poor practice and discuss ways of improving care.

One nurse said: 'Complaints are dealt with very quickly. We have changed our attitude so we can look at things earlier. We feel empowered and it's a learning tool.'

Strong leadership at ward level has created a culture of 'zero tolerance' for poor care: 'In my first month I had to suspend someone because of the way that they spoke to patients - that was a learning curve for me,' said one ward manager.

'I confront positively. If I see someone doing something I don't like, I pick it up straight away, and I don't let it fester,' she said.

However, this culture of clear expectations is complemented by management practices aimed at creating a supportive environment that values staff. For example, ward managers have adopted a flexible approach to working hours. 'We have slowly gained part-timers,' said one. 'They are a very stable team who keep going off and getting pregnant. And rather than lose them we have been flexible with their hours.'

Maintaining dignity
Patients' dignity is maintained largely through the manner in which staff approach intimate care procedures.

As one patient put it: 'I wanted the toilet and she said: 'Would you like to have a wash?' I said 'yes'. I feel some people can give you dignity, and she gave it. It's the way someone understands, talks to you. It's just the little things.

- The wards described in this article are due to close on September 17 as part of a reorganisation of acute medical services at the trust.

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